This course serves as an introduction to living in a world ...



A Mini Course

A Self-instructional Program

Approved for 1 Contact Hour

(This equals .1 CEU Credits for Iowa Nurses)

This study was prepared by Linda S. Greenfield, RN, Ph.D. for

This course serves as an update to help you live and work in a world containing the Human Immune Virus (HIV). It is a valid course for all of the states in which our courses are approved, but it has been designed to meet the specific requirements for the Florida HIV/AIDS update for healthcare workers.

Please read these IMPORTANT INSTRUCTIONS as they contain answers to many of the questions we are often asked regarding home study.

If you have downloaded this course, you may save it to your hard drive or print all or any part of it. In this way the document is available to you as a resource. As you leaf through this study, you will notice that there are questions placed throughout the reading material. Please notice the last two pages and print these if you have downloaded the course. The first is an answer sheet. As you complete the study, record your answers on this sheet. A passing score of 75% must be achieved to receive credit. In the event that you do not reach 75% on the first submission, you may try a second time without paying again. You must pay again if you need more than two attempts to pass the course. You may refer to the material at any time and you may also study in groups, if you wish. The second sheet is an evaluation form and is to be filled out and submitted along with your answer sheet. If you find any errors, please note them so we may correct them at the next printing. You may submit your answers online and your certificate will be available upon successful completion. Or you may fax your answer sheet to 206-600-6268, or mail it to: Nurse Learning Center 8910 Miramar Pkwy Miramar, FL 33025. Faxed or mailed answer sheets are processed within one week of receipt. You receive credit on the date we process your answer sheet. If you put your fax number on the answer sheet, we will fax back a copy of your certificate before we put the corrected answer sheet and a certificate of completion in the mail to you.

If you have multiple professional licenses, we will record up to three license numbers on your certificate. For those in Florida, the license number, along with the initial letters of the number, is VERY IMPORTANT, as this is the mechanism used to report your hours to CE Broker. For example, #432152 would be unusable. RN432152 would be the correct license number for a registered nurse. NO SPACES in your license number. If this is for initial licensure, please indicate this situation in the license number space on the answer sheet. Should you decide not to finish the course this year, it can be applied anytime up to two years from the date of purchase.

Initial Printing: January 1992

Current Revision: June 2010

This course has a very limited focus. Out of all there is to know about the diseases associated with the human immune virus (HIV), this course teaches what you need to know in order to help you prevent the spread of the disease. It details information about what you could teach others, because all of us in the healthcare professions are teachers in one way or another. It also supplies information you need to protect yourself. It doesn’t matter what occupation you work in or what position on the organizational chart you fill. You might be someone who happens to be at the bedside of a patient who is to receive an intramuscular injection of a drug to subdue his combative behaviors, and you join others to help restrain the patient. Legs and arms are flying as the nurse approaches the patient with her sharp needle in hand. Once that needle pierces the patient’s skin, you, personally, want to know where that sharp needle is until it is safely discarded. It is like a dangerous weapon in the room. Easily it could be kicked out of the nurse’s hand and land in someone’s foot. The National Institute for Occupational Safety and Health (NIOSH) estimates that there are 600,000 – 800,000 injuries per year with sharps (e.g. needle-sticks) among health care workers. (AORN, 3/2005) You need to know how to watch out for yourself and how to protect everyone else in that room. You might be an aide who was just bitten by a demented patient. What do you need to know to assure your continuing health? Who should you talk to? What should you expect to happen as a result of this bite? What are your legal rights? In this country we have passed the 1 million mark. Now, more than a million living people are infected with HIV. Every year it gets easier to be in contact with the HIV organism. Every year our need to practice with knowledge and safety increases. In the past, we had a greater chance of surviving moments of ignorance or lapses in concentration with the luck of the numbers. Luck never was enough protection.

This course is for you, and for everyone you encounter. Because when you know what you should know, and when you care, you will automatically seek to be safe. Then will your patients be safer as well. Some of the things we need to know are easily forgotten, especially when we don’t work daily in high-risk areas. It is a good idea for healthcare workers to frequently repeat a one-hour course on the topic. I ask you to do the obvious – read the course, even again if this is your umpteenth time through this material. Carefully. As if your health depended on it.

OBJECTIVES

No. 1: List the modes of transmission of the virus.

No. 2: Identify infection control practices and precautions for health care workers.

No. 3: List steps that can be taken to prevent the spread of HIV.

No. 4: Summarize the clinical progression, testing, & treatment objectives of the patient with HIV.

No. 5: Recognize the state's attempt to prevent discrimination and provide confidentiality to all.

Globally, HIV infections total more than 40 million people. In our country, over one million people are infected with HIV, however 1/4 of those have not yet been tested. They may not know about prevention and they are not receiving treatment. The incidence of new cases averages about 40,000 per year (Gallant, 2004), however some health officials believe that number is closer to 60,000. “We’re seeing more infections, that’s the bad news.” (Graham, 2005).

The epidemic in the United States is increasingly members of disenfranchised groups, such as young people, poor people and those socially marginalized. Nowadays, new HIV patients tend to be younger and are more likely to be minority and/or poor women. (Wurth, 2005) The fastest growing population of HIV positive people in our country is heterosexual young women, who now account for 28% of all new infections in the US, and approximately 69% of those cases are among non-Hispanic black women. (Leone, 2005) The rate of AIDS cases is not a uniform statistic in all races. In 2002, the rate of AIDS per 100,000 cases was 5.9 for whites, 8.5 for American Indians, 19.2 for Hispanics, and 58.7 for African Americans. (Campos-Outcalt, 2004) In young people13-19 years of age, women with HIV outnumber men. (Gallant, 2004) Together, African American and Latina women account for 82% of new HIV infections, but only comprise 30% of the US female population. (Aranda-Naranjo, 2005) HIV cases in all African-Americans are about 47% of those living with HIV. HIV cases among men who have sex with men make up 45% of those living with HIV. (Graham, 2005)

“The most common reasons reported by black women for engaging in behaviors that place them at risk for HIV infection were 1) financial dependence on male partners, 2) feeling invincible, 3) low self-esteem coupled with a need to feel loved by a male figure, and 4) alcohol and drug use.” (Leone 2005) We are missing the healthcare needs of this group of people. Reach out and teach as often as you can. Talk to these women whenever you have the opportunity. Maybe she just needs someone in the healthcare professions to care enough about her plight to notice her and put forth an effort to empower her. Florida hosts the third highest number of cumulative AIDS cases in our country and around 11% of our country’s reported cases. It ranks high in heterosexually acquired cases of HIV in women (over 40%) and is second in the nation of the number of AIDS cases among children. (Penny,2) Look at these numbers. You have ample opportunity to impact the lives of at-risk people.

While it is obvious that our prevention programs need to be reinforced and refocused, our treatment programs are also not reaching people uniformly or adequately. In one CDC study, about 40% of AIDS patients developed their symptoms within 1 year of being diagnosed. The average time between infection and the appearance of symptoms without treatment is 10 years, so these people were not discovered until quite late in their disease process, when drug therapy is less effective and nine years of preventive opportunities are now history.

The emphasis on controlling the spread of infection benefits everyone even when HIV is not involved. There are continual opportunities to teach and to encourage testing and treatment when necessary. If you don’t know how to connect people to the resources, call the HIV/AIDS hotlines. They know. They can help you find places to get tested or connect with treatment centers, even when there is no money or no insurance. The health of our culture is important to each and every one of us. We are the ones who are creating and managing healthcare. It seems obvious we have more work ahead of us. There is an ever-increasing need to include everyone in that cultural mission for health. We need new ways to approach the subject, a broader awareness of the obstacles, and stronger ways to provide opportunities to those who need our assistance.

MODES OF TRANSMISSION AND INFECTION CONTROL

You are the teachers. So what do you teach and how? Teaching can be in casual conversation just as easily as it is in a classroom. Your best teaching might happen in the break room over coffee when the conversation turns to sex. It might be when you hear that someone won’t use a public drinking fountain because they are afraid they will catch HIV from the fountain. Learn about how the disease is and is not spread and then share what you know with anyone who will listen.

Ways a person can become infected with HIV:

1. Having sex (vaginal, anal, or oral) with a person who is infected with HIV and not using barrier protection. It is passed through blood, semen, vaginal secretions, or blood contaminated other bodily fluids (e.g. saliva.) Other body fluids with an undetermined risk include: cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid or amniotic fluid.

2. Sharing needles and other drug paraphernalia with someone who is infected with HIV. There are small amounts of blood on the contaminated needles.

3. Receiving blood transfusions or blood products, donor tissue, or sperm for artificial insemination from someone infected with HIV. The blood and tissue banks adopted strict screening guidelines for HIV in 1985. This route of transmission is no longer a major route.

4. A baby being born to a woman infected with HIV can contract the disease during pregnancy, during birth and through breast-feeding. Perinatal and antenatal treatment has markedly lowered the rate of infant infections. In 2003 only 5 babies were born with HIV in New York City.

5. Among health care workers, HIV can be transmitted when injury with sharp objects contaminated with HIV occurs, or if splattered in mucous membranes or non intact skin dermatitis, chapped or abraded skin) by HIV contaminated blood, through improper handling of cultures of HIV virus. Transmission can also occur with contact with intact skin when the duration is several minutes or more, or if contact involves an extensive area in contact with blood tissue or other body fluids.

Those most at risk are people who engage in high risk sexual behaviors, injectable drug users who share paraphernalia, sexual partners of members of high-risk groups, any who think it can't happen to them or their loved ones, and those who refuse to be educated. Basically, No Sex, No Drugs, No Blood, No Risk.

Things that DO NOT spread HIV:

❖ Exposure to saliva, tears, sweat, urine or feces with no visible blood.

❖ Common use of public facilities such as restrooms, pools, spas, water fountains, etc.

❖ Contact with clothing, food, dishes, utensils, toilet seats or even chewed pencils.

❖ Standing close to someone who has it.

❖ Breathing, sneezing, touching, coughing, wrestling.

HIV is a sexually transmitted disease. Despite the risk, it has been difficult to deliver the message in such a way that behaviors change. Personal, social and cultural barriers exist in almost every nation and government. In our own country we still have several examples in which abstinence is the only preventative measure taught or offered to our teen-agers, despite the fact that this group has the highest rate of sexually transmitted diseases. “…some evidence shows that abstinence-only education increases the level of sexual activity in young persons.” (Gallant, 2004) Many adolescents DO engage in sexual behaviors. “Sex education leads to a delay in the onset of sexual activity or a decrease in sexual activity and increases safer sex practices.” (ibid)

It is a concern for not only our youth. Many older adults DO have sex with multiple partners but do not admit it. Many HIV-positive people ARE having sex without protection. These are realities. We need to teach accurate and complete information, including information about condom use. These are messages that need to be taught over and over.

Sexual expression is highly individual. What one person considers normal, another would consider unacceptable. In order to teach prevention principles, the total range of sexual activity needs to be considered. I'll list for you activities considered safer, risk reducing, and high risk, without judging any of these activities as normal or abnormal, appropriate or inappropriate. The principles of sexual risk apply to any risk situation: male / male; male / female; female / female; or whatever combination exists.

No Risk

Most of the really safe activities involve only skin-to-skin contact where transfer of the virus is unlikely from one person to another.

1. Abstinence.

2. Mutual masturbation (male or female) (without semen or vaginal fluids)

3. Social kissing (dry)

4. Body massage, hugging

5. Body-to body rubbing

6. Nipple stimulation.

7. Erotic bathing or showering..

8. Using one's own inserted sexual devices.

9. Contact with feces or urine on intact skin.

While abstinence would be the desired or ideal behavior to prevent HIV transmission, it would be blind to consider it the only choice people will make. In studies of sexual behaviors of HIV positive persons, abstinence from sexual relationships occurs in a minority. It is important to provide people with the spectrum of information about sexual risk.

Theoretical Risk

1. Wet kissing.

2. Cunnilingus (oral-vaginal stimulation) with barrier protection.

3. Digital-anal and digital-vaginal intercourse, with or without a glove and with intact skin.

4. Using shared, but disinfected inserted sexual devices.

Risk Reducing Sex

In these activities, small amounts of certain body fluids may be exchanged, causing some risk. This risk is increased in proportion to the number of contacts.

1. Intercourse with a condom. This is safe if the condom does not break, causing spillage of semen into the vagina or rectum. The risk is also reduced if withdrawal occurs before climax. Latex condoms may breakdown from heat, and other factors, but this type is recommended. In cases of latex allergy, non-latex alternatives are available. Those from natural membranes (e.g. lamb cecum) do not block HIV. Oil based lubricants, including petroleum jelly, vegetable shortening, butter, etc. should not be used because they increase the risk of condom breakage. Water-soluble lubricants such as K-Y jelly or diaphragm jelly can be used. Condoms impregnanted with nonoxynol-9 do not increase prevention of sexually transmitted diseases

2. Fellatio. This is the term used to describe oral sex, or sucking on the penis. Since pre-ejaculatory fluid may have virus in it, there is some risk in this practice. Also the risk is increased if there are mouth sores. Many teenagers think that if they engage in oral sex, they are successfully preserving virginity. Oral sex without protection is not safe sex. A condom (or dental dam) is recommended for any fellatio activity. If a condom is not available, nonporous (nonmicrowaveable) plastic wrap may be used. Fellatio with ejaculation and ingestion of semen carries more risk than fellatio with a condom.

3. Cunnilingus. This is the term used to describe oral stimulation of the female perineum. Since both saliva and vaginal secretions are known to contain the virus, there would be some risk. If menstruation is occurring, risk is increased. Dental dams or nonporous plastic wrap is advised.

High Risk Sex

1. Penal-vaginal intercourse, or penal-anal intercourse without a condom.

2. Intercourse with withdrawal before ejaculation

These activities involve tissue trauma and or exchange of body fluids that may transmit HIV or other microbes. They are high risk unless the sex partners have been monogamous (only one partner) and healthy for five years or more. It is important to recognize how some people interpret the word "monogamous." Some, when describing their monogamy, are actually describing "serial monogamy", in which the person may have had only one partner at a time, but had had multiple partners since becoming sexually active. Without adequate protection, this would be high-risk behavior. Many apparently assume that if they have no knowledge that their partner was infected or engaged in high-risk behavior, then unprotected sex was not unsafe sex. Encourage people to inquire deeply about a potential partner's risk status, and to consider the potential for dishonesty. It is also important to consider the number of young women who engage in unprotected anal sex for the purpose of preserving virginity. Many teens do not consider oral or anal sex to be “sex”, and so do not apply safety information to these activities. Be very clear in your teaching opportunities to specify the dangers of unprotected oral, vaginal, or anal sex.

Protection for Injecting Drug Users:

Teaching efforts are necessary to reach those in danger of transmitting HIV through contaminated needles. This is one of the highest-risk groups and is a leading factor in spreading HIV. Although the message to not share needles has been widely distributed, few injecting drug users will be stopped from injecting just because only one used needle is available. Multiple efforts are necessary to reduce the impact of this mode of transmission. Approaches to the problem include, but are not limited to:

• Needle and syringe exchange programs are available in many larger cities. This provides access to sterile needles. Numerous studies in several countries have demonstrated that this practice can reduce the incidence of blood-borne disease and it does not increase drug use.

• Needles and syringes can be sterilized using a bleach solution of 1 part bleach to 9 parts water. There are bleach kits available, usually given free of charge at treatment program centers. One teaching plan employs the “3x3 method.” 1) Fill the syringe with water, shake it and empty it. Do this three times. 2) Fill the syringe with straight bleach, tap it for 30 seconds and drain it. Do this three times. 3) Fill the syringe with clean water. Shake it and empty it. Do this three times.

• Efforts are ongoing to increase access to health services and drug treatment programs, with a major goal to decrease the spread of HIV.

Question No. 1: The group with the highest rate of sexually transmitted diseases is:

a. 20-40 years old.

b. 40-60 years old.

c. Teenagers.

d. Senior citizens.

Question No. 2: Which of these is NOT true of the current statistics of HIV/AIDS in our country?

a. Forty percent of AIDS patients developed their symptoms within one year of being diagnosed.

b. HIV cases among men who have sex with men make up 69% of those living with HIV, a clear majority.

c. In young people 13-19 years of age, women with HIV outnumber men.

d. Together, African American and Latina women account for 82% of new HIV infections.

Question No. 3: Which is a false description of serial monogamy?

a. This describes low-risk or no-risk behavior even without condom use.

b. This means the person has only one sexual partner at a time, but multiple partners since becoming sexually active.

c. This is high-risk behavior if adequate protection is not used.

d. This is not the same as monogamy, which means the partner is the same and only one for five years or more.

Question No. 4: True or False? Oral/vaginal stimulation (cunnilingus) with barrier protection (e.g.

nonporous plastic wrap) is considered theoretical risk.

a. True. b. False.

Question No. 5: No-risk sexual activities:

a. Do not involve semen or vaginal fluids.

b. Includes social kissing.

c. Involve only skin-to-skin contact.

d. All of these describe no-risk sexual activities.

Question No. 6: Among healthcare workers, which of these is NOT a way that HIV can be

transmitted?

a. When a healthcare worker’s intact skin contacts the patient’s urine, which has no visible blood.

b. When HIV-contaminated blood has contacted the worker’s intact skin for several minutes or more.

c. When the worker’s mucus membranes (e.g. the eye) is splattered with HIV-contaminated blood.

d. When the worker’s skin is injured with a sharp needle contaminated with HIV.

Things to Teach a Person With A Positive HIV Antibody Test:

• To avoid sexual activity or inform the partner of the positive HIV exposure, and then provide protection from body fluids during sex. Condoms should be used, and any practice that may injure body tissues should be avoided. Oral-genital contact and open-mouthed, intimate kissing should be avoided without protection.

Do not assume that after given an HIV positive diagnosis, persons become asexual or do not want to become involved in intimate relationships. Studies show otherwise. Teaching needs to be constantly reinforced.

Even if both partners are HIV positive, it is important for them to practice safer sex or risk-reducing behaviors. They could infect one another with different HIV strains or other sexually transmitted diseases, compromising the success of their therapy. HIV-positive people following their drug therapy regime closely, who now have "undetectable" viral loads, can still transmit HIV to other people. The word "undetectable" merely means that our laboratory equipment is not yet sophisticated enough to be able to measure HIV hidden in body reservoirs. The HIV is still in the person's body, just not in the blood stream where it could be measured. It can be transmitted.

• To have regular medical evaluations and follow-up.

• To inform present and previous partners and any persons with whom needles may have been shared, of the potential exposure to HIV and encourage all involved to seek counseling and antibody testing at appropriate care facilities. Teach them never to share needles and other drug equipment.

Many HIV-positive people DO NOT disclose their HIV status to their partner.

• To not donate blood, plasma, organs, body tissue, or sperm.

• Not to share toothbrushes, razors, or items that could be contaminated with blood.

• To clean blood or other body fluid spills on household surfaces with freshly diluted household bleach, i.e. 1 part bleach to 9 parts water. Don't use bleach on wounds. Bleach is recommended, although many disinfectants are appropriate. Bleach maintains its potency for only 24 hours, so it must be reconstituted daily.

• To inform healthcare workers of the positive HIV status, so that proper precautions can be taken to protect all. The fear is that the health care worker may refuse to provide care. The Americans With Disabilities Act (ADA), supported by the interpretation of Bragdon v Abbot, provides protection to those with HIV.

• HIV-positive women should avoid pregnancy. However, most women learn of their positive HIV status because of their pregnancy. As many as two thirds of HIV cases in women are diagnosed during pregnancy. Even among women who are aware of their HIV status, research suggests that the positive HIV status is NOT the major influence in reproductive decision-making. Many social, psychological, and economic issues are of more importance to her current survival. Her limits of control, and poor economic resources are major factors that contribute to the HIV/AIDS risk of certain groups of women, and impact how women are able to deal with the disease. “Says UN special AIDS envoy Stephen Lewis: “Until there is a much greater degree of gender equality, women will always constitute the greatest number of new infections. You cannot have millions of women effectively sexually subjugated, forced into sex which is risky without condoms, without the capacity to say no, without the right to negotiate sexual relationships.” (Ellwood, 2002)

All pregnant women should be screened for HIV. (7/2005, Agency for Healthcare Research and Quality)

Safety Implications for Health care workers:

Those who care for patients with AIDS or process their specimens carry a low risk when appropriate precautions are taken. The risk is small, but real. For example, human bites carry a potential risk, yet HIV transmission through bites has rarely been reported. If blood is involved in the bite, the health care worker should be offered prophylactic therapy. Of the documented cases, the greatest majority was from percutaneous injury (e.g. needle-sticks).

“Over 80% of needle-stick injuries can be prevented with the use of safer needle devices, which, in conjunction with worker education & work practice controls, can reduce injuries by over 90%.” (Foley, 2005)

Suture needles are less likely to transmit HIV than are hollow bore needles, such as those used for IM injections. A small gauge needle carries less risk than a large gauge needle. If the needle went through gloves before sticking into the skin of the healthcare worker, approximately 50% of the blood is removed, which decreases the risk of contamination. “When two pairs of gloves are worn (ie double gloving), in most instances, only the outer glove is perforated when punctured by a sharp device…In addition, research demonstrates that when two pairs of gloves are worn and a puncture occurs, the volume of blood on a solid sharp device (e.g. suture needle) is reduced by as much as 95%. “ (AORN, 2005) Double glove when the risk is high. Use gloves for sub-q injections, IM injections, when using a needle and syringe to irrigate a wound, and certainly for IV procedures.

Always point sharps away from staff members. Use verbal notification when passing a sharp device. Avoid bringing anyone’s hands, including yours, close to the opening of a sharps container. Encourage retractable, protective sheath or self-re-sheathing, self-blunting or hinged recap needles when injections are necessary. Identify sharps containers with orange or red-orange labels noted with the biohazard label, that are closable.

AZT or AZT with Lamivudine (3TC) is often recommended to be used immediately. The CDC web site posts the current protocol, which is kept updated at If the risk is higher, a protease-inhibiting drug is also recommended. Treatment should be started within 1 to 2 hours of exposure, and continues for 28 days. Beginning these drugs more than 72 hours after exposure probably will not prevent infection, but may be beneficial to therapy. The doctor and patient need to weigh the potential toxicity of these combined drugs against the potential benefit of therapy. With appropriate antiretroviral therapy, the risk for HIV seroconversion can be reduced by 79%-81%. Significant side effects have been reported from healthcare workers treated with post-exposure prophylaxis (PEP).

Universal / Standard Precautions

CDC Recommendations for Healthcare Worker’s Precautions:

• Avoid accidental wounds from sharp instruments such as scalpels and needles, which might be contaminated with material from any patients.

• Avoid contact of open skin lesions with material from any patient.

• Wear gloves when handling blood specimens, blood-soiled items, body fluids, excretions and secretions, or when handling any objects that have been exposed.

• Wear gowns when clothing may be soiled by any body fluids.

• Wash hands after removing gown and gloves, and especially if hands have been contaminated with blood.

• Label specimens with "Standard / Universal Precautions" and transport them in impervious containers.

• Clean blood spills with disinfectant solutions.

• Place articles soiled with blood in an impervious container labeled "Standard / Universal Precautions" before sending for reprocessing or disposal.

• Place needles in a puncture resistant container after use without bending the needle. Needles should not be replaced in their sheaths after use, as this is a common cause of needle injury. This procedure accounted for 30% of all needle sticks according to one study.

• Use disposable needles whenever possible. There is growing support for safer devices for needle disposal and needle-less systems.

• Place patients in private rooms if they are too ill to practice good hygiene with regard to body secretions.

Universal precautions is not a synonym for "infection control". Universal precautions means taking steps to protect staff and patients from infection by blood and bodily fluids, such as Hepatitis B, HIV, and multiple other blood borne diseases. There are many infectious risks, however, in which the blood is not the mechanism of transmission, so other infection controls procedures (respiratory isolation, wound and enteric precautions, etc.) are necessary if the organism is other than HIV.

If an invasive procedure is required (operating room, delivery room, emergency department or outpatient, dental procedures in which bleeding may occur), additional precautions are recommended by the CDC. All health care workers participating in the invasive procedure should wear gloves, surgical masks, protective eyewear, and gowns or aprons which are made of materials known to be an effective barrier, especially if splashing of blood or body fluids could result. These items are collectively referred to as "personal protective equipment". Hand care and glove use will be considered in detail.

❖ Wearing gloves does not eliminate the need to wash your hands between patients and before invasive procedures, etc. When you have worn gloves, your moisture level of your hands has increased, and your microbial count increased. Organisms can penetrate through microscopic tears.

❖ Don't store latex gloves longer than 6 months, and keep them away from ultraviolet and fluorescent lights. These weaken the integrity of the gloves. Check the expiration date on sterile-glove packages and keep them current.

❖ Gloves are single use items. Use them and toss them. Do not wash the gloves and continue to the next patient. This weakens the glove and organisms are not always removed from gloves, despite friction, the cleansing agent and drying.

OSHA mandates gloves when there is "a reasonable likelihood of hand contact" with blood or other potentially infectious material, mucus membranes, or non-intact skin, and when performing invasive procedures and handling contaminated items or surfaces. From a cost-containment perspective, it is important to know when gloves are not necessary:

• To bathe a patient, unless you will bath the genitalia, or contact body fluids.

• To wash hair,

• Assist a patient to the bathroom,

• Ambulate a patient with a catheter,

• Take vital signs,

• Change IV bags,

• Routinely change bed linen,

• Feed patients,

• Provide enteral feedings, or

• Care for a stage 1 ulcer (intact skin).

Aside from handwashing and gloves, there are other decisions your facility or you will make in regard to protection and infection control. When do you want to wear a gown or a mask or eye protective equipment? In making your choices beyond those mandated by facility policy, you'll need to think in terms of possible risk. For example, if you are changing the dressing on a wound or a pressure sore, probably gloves with handwashing will be enough protection. But, if you are going to irrigate that wound, there might be backsplash in some combative patient situations. If so, you may need a moisture proof apron or gown, goggles, a mask or a face protector as well as gloves. It really doesn't matter if I you know there is an infection or not. You treat all patients alike -- as if they are HIV and Hepatitis positive.

Question No. 7: True or False? As many as 2/3 of HIV cases in women are diagnosed during

pregnancy.

a. True. b. False.

Question No. 8: Which of these is an example of good glove practice?

a. Storing latex gloves longer than 6 months and then using them.

b. Using a single pair of gloves for multiple patients.

c. Using gloves to change a standard bed.

d. Washing hands between patients and before invasive procedures.

Question No. 9: True or False? If both partners are HIV positive, it is no longer important for

them to practice risk-reducing behaviors.

a. True. b. False.

Question No. 10: When a potentially contaminated needle is in the area, what procedures can help

prevent injuries?

a. Always point the needle away from others and self.

b. Avoid hands in close proximity to the opening of the sharps container.

c. Use verbal notification (e.g. “I’m passing a used needle,”) when passing a sharp device.

d. All of these may help.

Clinical Progression from HIV infection to AIDS

HIV does not itself kill the patient. It creates the possibility for the opportunistic infections and certain forms of cancer to cause death. When these diseases appear, the person is given the diagnosis of AIDS. Opportunistic infections are from organisms most of us already have in our bodies, or are readily in the environment. They are certain bacteria, viruses, protozoa and fungi that are allowed to increase and create disease because the hampered immune system cannot keep them in check. Fortunately, the list does not include all organisms. The list of opportunistic infections does not include the common cold; but flu, colds and stress should be avoided as much as possible. AIDS (Acquired ImmunoDeficiency Syndrome) comes indirectly from a defenseless, viral-destroyed immune system.

The portion of this system most affected by HIV is the T-lymphocytes (T-cells) in the blood. T-cells, also called T-4 cells or CD-4 cells, are the controlling cells of immunity. They are white blood cells. They protect against certain infections and some cancers. T-cells are destroyed by HIV, leaving a person susceptible to these specific infections and cancers.

There is no cure, as we have nothing that will completely eliminate the virus from the body. There is no preventative vaccine, and it appears unlikely that we will have one in the foreseeable future. Prevention of HIV transmission remains our primary objective.

The development and diagnosis of HIV disease, which may progress to AIDS, occurs in stages, but the stages vary widely. Following infection without treatment, 7 to 10 years pass during which many (50%) patients have no symptoms. With the use of medication, this period of time is being stretched. Psychological symptoms of grief, regret, depression, etc. often occur. Medical care may involve antiviral drugs, and monitoring of immune functioning and side effects. The need for constant encouragement to be incredibly faithful to the drug regime cannot be overlooked. Health care involves emotional support, educational support, education concerning HIV transmission, and encouragement for life planning tasks such as durable powers of attorney, decisions regarding child custody, etc There is hope that with the use of multiple combinations of antiretroviral drugs, the immune system can remain intact, and the patient will not progress to AIDS. The long-term effects of life-long therapy with antiretroviral drugs are not known. This requires a relatively early diagnosis of HIV infection, which is not always possible.

As the years pass, diseases and symptoms that appear (such as weight loss, or mild opportunistic infections) can be treated and the person returns to a prediagnostic level of functioning. Prophylactic drugs for opportunistic infections are often added to the regimen.

Symptoms that indicate AIDS or various opportunistic infections may include:

• chronically swollen lymph glands, usually in the neck, armpits, or groin, lasting longer than two weeks,

• drenching night sweats, unexplained fever or shaking chills lasting several weeks,

• unexplained weight loss more than 10 pounds in 2 months, with loss of appetite,

• severe or chronic persistent diarrhea,

• unexplained persistent fatigue,

• yeast infections in the mouth, unusual white spots like cottage cheese,

• unexplained fever lasting more than a week,

• leg weakness, difficulty climbing stairs,

• white sores in the mouth and a thickening and overgrowth of mucous membranes of the body,

• shingles--a painful viral disease characterized by blisters which develop along a nerve path. It is rarely seen in persons with healthy immune systems and under 50 years of age,

• lymphoma--cancer of the lymphatic system. This can be the only clinical sign of altered immunity, and the first warning sign of AIDS.

The presence of these symptoms warns that something is wrong, but does not indicate for certain that a person has AIDS. Later symptoms:

• pink to purple flat or raised blotches or bumps occurring on or under the skin, the inside of the mouth, the nose, eyelids, or rectum. Initially they may resemble bruises, but they do not disappear. They are usually harder than the skin around them. Many of the first manifestations are seen in the skin.

• persistent, dry cough which lasts too long to be caused by a common respiratory infection, especially if accompanied by shortness of breath.

Opportunistic infections or Karposi's Sarcoma causes symptoms that are specific to the particular type of infection or cancer. The definition of AIDS involves twenty-six specific clinical conditions, including pulmonary tuberculosis, recurrent pneumonia and invasive cervical cancer. Cervical cancer is 8 to 11 times greater in women with HIV. The definition of AIDS also includes those persons who test HIV positive and who have CD-4 (T-cell) counts below 200/mm3, but who do not have an AIDS defining opportunistic infection or malignancy. Thus, it is possible (but unusual) to have AIDS without having symptoms of disease.

As opportunistic infections begin to compound, the person begins to deal with numbers of chronic conditions that may be controlled, but not cured. Few of the viral, parasitic or fungal opportunistic infections complicating HIV can be cured with our current drugs. There will be multiple symptoms, multiple drugs and drug side effects, multiple doctors’ visits and multiple bills.

Diagnostic Testing

Tests can detect the antibody to HIV, and a positive test may mean that the person has been exposed. It does not mean the person will necessarily develop AIDS. The general standard followed at this time is that if a person remains seronegative for at least 6 months after exposure, their risk of infection is very low. Typically, the time between initial contact with the virus and seroconversion (the time when antibodies develop against HIV) may be from two weeks to six months, and rarely perhaps as long as 3-4 years. The majorities will seroconvert within 6 to 12 weeks. It is important to emphasize that ONCE INFECTED, EVEN IF IT NEVER ACTIVATES, THE VIRUS CAN BE TRANSMITTED THROUGH BODY FLUIDS AND INFECT OTHERS, FOR AS LONG AS LIFE. "Walking wounded" is the name given to the people walking around infectious, many of whom don't even know they are positive.

Oral testing (e.g. OraSure) for HIV antibodies is accurate and results can be available within an hour. The person being tested swabs once around the outer upper and lower gums, and inserts the swab into a vial containing the testing solution. The test is 99% accurate. Another form of this rapid test uses a drop of blood. The OraQuick ADVANCED Rapid HIV-1/2 Antibody test provides results in about 20 minutes. The Uni-Gold Recombigen rapid HIV test rovides results in 10 minutes. Only FDA approved HIV tests should be used. These newer rapid screening tests allow patients to be tested and counseled when they receive their test results, in a single session. This is important because often people fail to return for their test results. The CDC’s new initiative encouraged HIV testing to become a routine part of medical care. This offers earlier detection and treatment of infected persons, and a short period during which the infected person may unknowingly transmit the infection to others. Testing is more acceptable if it is implemented as a routine test with a choice to opt out.

Persons infected will be infected for life. No one can predict absolutely who among will be ill or fatally ill in the future, nor is it known how to totally prevent such outcomes, although treatment continues to improve the statistics. All persons who test positive, whether they are symptom free or ill, must be considered to be potentially infectious to others by sexual transmission, by sharing of drug injection equipment, by childbearing, or by donation of blood, semen, or organs. All HIV-positive persons should seek information on how to protect their sexual contacts and future children.

HIV testing is with formal consent. The times when testing can be done without consent are very few, and very specific. If consent is not available, clarify the situation with the doctor or a person who is legally knowledgeable before drawing the test. Courts can order HIV testing, but only in unusual or specific circumstances. Each state determines what these circumstances are, so there are variations in rights from state to state. With a court order, individual consent is not required. In Florida, an individual accused of rape must be tested. And whenever a physician determines that a healthcare worker has had "significant exposure", the source's blood sample can be tested for HIV without his permission. If no sample is available and the source refuses to be tested, a court order for mandatory testing can be obtained. Before this is done, the worker must consent for testing of the HIV. Specific criteria must be met throughout the process. In Florida, pregnant women are strongly encouraged to be counseled and tested. If the woman refuses testing, efforts must be made to obtain a written statement of that refusal, and the statement is included in her permanent record.

Voluntary testing can be confidential or anonymous. Confidential testing keeps the results available to only health care authorities with a "need to know". Mandatory reporting of positive status to governmental health authorities is becoming more prevalent. Mandatory reporting of AIDS to the CDC has been in existence since the disease became widespread, but mandatory reporting of HIV infection has not. Florida has had mandatory reporting of both positive HIV status and AIDS since 1997.

There are Alternative Test Sites that can protect a person's anonymity. Testing, confidential counseling and partner notification services are all available. These designated places allow a person to be tested without providing name, address, social security numbers or any other official identification numbers. To obtain an anonymous test, you call a number available from the AIDS hotline number for each state.

There are at-home tests that can be ordered through the mail. If properly done these tests can be accurate, however, the tests provide no counseling and tend to be expensive. Health departments offer free and anonymous testing that provides pre and post testing counseling and referrals. All testing should provide pretest counseling, post test counseling, and follow-up counseling.

Confidentiality is important. The test results can only be given to the person being tested, his legal representative, or foster or adoptive parents. Specific written permission has to be obtained for release of information, and even then, only those with a clear "need to know" can have access to this information, whether the test is positive or negative. Healthcare providers consulting together or with health care facilities can have access to the information if it is necessary for the diagnosis or treatment of the patient. Departments of health have access to statistical AIDS/HIV information. Those providers that receive, process and distribute donated blood, plasma, organs, semen, etc. can assure those materials are HIV free. Authorized researchers of HIV/AIDS have access to limited information. Medical records that contain HIV information can only be released when specifically authorized by the patient in writing, or there is a court order to do so.

Once the patient is diagnosed as HIV positive, the activity of the infection and effectiveness of therapy is monitored through the viral load assay tests. These tests measure the presence of HIV in the blood. One common one measures the numbers of HIV RNA copies in the plasma. Current treatment guidelines aim to maintain the viral load below 500 copies per ml. Keeping the load as low as possible seems to provide more protection from drug resistance, but it is sometimes difficult to keep a patient at this very low level. The patient’s response to treatment and progression of disease is often monitored with a CD4 count and percentage. This is the number of helper T-cells in the circulating fluids. Normal is 600 to 1200 cells / mm3. The percentage is greater than 40%. A patient with 18% T4cells and only 172 cells counted is very likely to develop opportunistic infections. The degree of risk for certain infections can be estimated with the CD4 count. The CD4 cell count tells you roughly where the patient is at the moment; the HIV RNA level indicates how rapidly the disease is progressing.

Treatment Objectives

Effective drug therapies are changing the course of HIV disease. If drug therapy can slow the viral destruction of the immune system, then the onset of opportunistic infections is delayed. The standard of care for HIV therapy is called “highly active antiretroviral therapy (HAART). Most feel that treatment should start as early as possible. There are multiple anti-HIV drugs available, divided into classes based upon the way they stop HIV from killing the T-cells. Combination therapy may cost $20,000 per year, and many lack insurance coverage. The AIDS Drug Assistance Programs, (ADAP) administered by the state’s health department, can help, but several states have waiting lists. Be sure to provide access to this resource in your teaching. Each state's process varies slightly, but generally a person is able to receive financial assistance if he earns less than $44,000 a year, and has less than $25,000 in assets not including his home or car. For information, call the Access Project at 800-734-7104.

The patient must follow his regimen completely and totally. Missing doses is very dangerous, and even mistiming doses can create problems. According to the CDC, only 65% of people on triple drug therapy say that they take the complicated regimen as prescribed. Another 25% say they usually take it correctly, and 9% confess to taking their medications sometimes or never. Probably the most limiting problem is drug resistance, which is far more of a risk if the patient does not follow the prescribed drug regime. The challenges include extensive patient education and support, as the patient struggles with drugs that sometimes make him feel worse than he did before therapy.

Coordinating care for the HIV/AIDS patient involves knowledge of a wide variety of federal, state and local programs that provide a variety of assistance. There are many other organizations providing assistance besides the American with Disabilities Act and the AID Drug Assistance Program:

CDC National AIDS Hotline: 800-342-AIDS

HIV/AIDS Treatment Information Services: 800-448-0440

National AIDS Fund: 202-408-4848

National Association of People with AIDS: 202-898-0414

State hotline numbers include:

Southern California 800-922-2437 (TTY/TTD) 888-225-AIDS

Northern California 800-367-2437 (TTY/TTD) 415-864-6606

Florida (in state) 800-352-AIDS (English) or 800-545-SIDA (Spanish)

Iowa (in state) 800-445-2437

An excellent web site to help you find state by state resources is Other excellent web sites are: JAMA HIV/AIDS Information Center CDC National AIDS Clearinghouse National Library of Medicine Internet Grateful Med

Obviously, discrimination against those with AIDS has happened in the past and even with legal restrictions, is still happening. People who test HIV positive do not lose their constitutional rights. The use of tests must be informed, voluntary and confidential. The person being tested must be informed in a manner he can understand, and he must receive information about the test, the prevention and treatment of the disease, and the confidential nature of the testing.

Question No. 11: All but one accurately describes treatment of HIV disease. Which does NOT?

a. The cost of treatment can be quite high, but there are state programs of financial assistance for those without insurance.

b. Most feel that drug treatment should start late in the infectious process after AIDS is diagnosed.

c. Treatment involves multiple drugs with side effects and drug interactions to manage.

d. The patient must follow his regime completely and totally.

Question No. 12: Which is NOT true of an opportunistic infection?

a. Most of these infections that complicate HIV can be cured with our current drugs.

b. One of the ways that AIDS is diagnosed is when opportunistic infections begin to appear.

c. These are infections from bacteria, viruses, protozoa, or fungi that, for the most part, are readily encountered, but usually a healthy immune system would take care of them.

d. These are infections that are allowed to create disease because the immune system has progressively been destroyed so it can’t fight.

Question No. 13: True or False? Following infection with HIV, without treatment, 7-10 years pass

during which 50% of patients have no symptoms.

True. b. False.

Question No. 14: Which of these is NOT true of HIV testing?

a. In Florida, HIV testing during pregnancy is mandatory.

b. It must be with formal consent.

c. Results can be available within an hour with oral testing.

d. The test detects antibody to HIV and if positive, this means the person has been exposed.

Question No. 15: Symptoms that may indicate an opportunistic infection or AIDS include:

a. Drenching night sweats with unexplained fever or chills lasting several weeks.

b. Loss of weight with loss of appetite.

c. Swollen lymph glands lasting longer than 2 weeks.

d. All of these are possible symptoms.

BIBLIOGRAPHY

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Multicultural Nursing & Health, Winter, 2005.

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Beadle de Palomo, Frank, “AIDS: 25 Years Later”, , June 5, 2006.

Brink, Susuan, “A Fast and Furious Virus,” US News & World Report, February 28, 2005.

Campos-Outcalt, Doug, “HIV Prevention Enters a New Era,” Journal of Family Practice, July 2004.

Ellwood, Wayne, “We all Have AIDS,” New Internationalist, June 2002.

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Foley, Mary, “Needlestick Safety and Prevention,” Nevada RNformation, February 2005.

Gallant, Joel, “HIV Counseling, Testing, and Referral, “American Family Physician, July 15, 2004.

Gallo, Robert, “HIV/AIDS Research After HAART,” Research Initiative/Treatment Action, Summer 2005.

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Goodier, Rob, “Contraceptives Don’t Hasten HIV Progression – and May Protect Against It,”

viewarticle/723338, June 2010.

Graham, Chad, “Colliding Epidemics:,,” The Advocate, July 19, 2005.

Harder, B., “Fast Start: Sex Readily Spreads HIV in Infection’s First Weeks,” Science News, April 23, 2005.

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James, Jolin, “If the condom breaks”, AIDS Treatment News, June 28, 2005.

Katz, I. Et al, “Risk Factors for Detectable HIV-1 RNA at Delivery Among Women Receiving Highly Active Antiretroviral

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Kenslea, Ged, “AIDS treatment Goes Global,” USA Today, March 2006.

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Penny, Jean, "HIV/AIDS," Vital Signs, CE Course #253, pg. 1-8.

Schneider, Mary, “HIV/AIDS Drug Waiting List,” OB/GYN News, May 15, 2005.

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viewarticle/723870, Jjune 18, 2010.

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Splete, Heidi, “Dug Resistance Factors Into Treatnent Failures,” OB/GYN News, November 1, 2005.

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Yarber, William, “Public Opinion about Condoms for HIV and STD Prevention,” Perspectives on Sexual and Reproductive Health, September 2005.

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